Topical Androgens Prior Authorization Request Form printable pdf download

Please note: All information below is required to process this request

Mon-Fri: 5am to10pm Pacific / Sat: 6am to 3pm Pacific

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and click Health Care Professionals

OptumRx • M/S CA 106-0286 • 3515 Harbor Blvd. • Costa Mesa, CA 92626

Topical Androgens Prior Authorization Request Form (Page 1 of 3)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Member Information

Provider Information

(required)

Member Name:

Provider Name:

Insurance ID#:

NPI#:

Specialty:

Date of Birth:

Office Phone:

Street Address:

Office Fax:

City:

State:

Zip:

Office Street Address:

Phone:

City:

State:

Zip:

Medication Information

(required)

Medication Name:

Strength:

Dosage Form:

 Check if requesting brand

Is the physician supplying the medication?  Yes  No

Continuation of therapy?  Yes  No If “YES”, answer the following:

Directions for Use:

Has member been on this medication in the last 180 days?*  Yes  No

Does the prescriber confirm that the medication has been effective in treating

the member’s medical condition?*  Yes  No

Clinical Information

(required)

Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s

benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan

specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,

prescription benefit coverage will be determined based on the benefit plan’s rules.

Select the requested drug below:

 Androderm

 Androgel (testosterone topical gel)

 Axiron

 Fortesta

 Natesto

 Striant

 Testim (testosterone topical gel)

 Vogelxo

Select the diagnosis below:

 Hypogonadism in men

 Female to male transsexual person

 Other diagnosis: ______________________________

Hypogonadism in men*:

Does the member have two pre-treatment serum total testosterone levels less than 280ng/dL (< 9.7 nmol/L) or less than the reference

range for the lab, taken at separate times?  Yes  No

Please document all pre-treatment level(s) below and date taken:

Pre-treatment total Testosterone level 1: ________ Reference range: ____________ Units of measure: ________ Date taken: _________

Pre-treatment total Testosterone level 2: ________ Reference range: ____________ Units of measure: ________ Date taken: _________

Calculated free or bioavailable testosterone level:

Does the member have one pre-treatment calculated free or bioavailable testosterone level less than 50 pg/ml (<5 ng/dL or < 0.17 nmol/L)

or less than the reference range for the lab?  Yes  No

Please document the level(s) below and date taken:

Pre-treatment calculated free or bioavailable Testosterone level: ______________

Reference range: _______________

Units of measure: ______________

Date taken: ____________________

Does the member have a condition that may cause altered sex-hormone binding globulin (SHBG) (e.g., thyroid disorder, HIV disease, liver

disorder, diabetes, obesity)?  Yes  No

Select if the member has a history of one of the following:

 Bilateral orchiectomy

 A genetic disorder known to cause hypogonadism

 Panhypopituitarism

(e.g., congenital anorchia, Klinefelter's syndrome)

Select if the member has one of the following:

 Decreased bone density

 Decreased libido

 Osteopenia

 Osteoporosis

 Organic cause of testosterone deficiency (e.g., injury, tumor, infection, or genetic defects)

 Significant reduction in weight (less than 90% ideal body weight) (e.g., AIDS wasting syndrome)

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider

named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose

PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information

in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: TopicalAndrogens_UHCE&I_2016Dec-W.doc